Patterns of Polysubstance Use in Young Black and Latinx Sexual Minority Men and Transgender Women and Its Association with Sexual Partnership Factors: The PUSH Study

Background: Adult studies have demonstrated that polysubstance use increases HIV acquisition risk through increased sexual behaviors, however, few studies have examined polysubstance in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Methods: We used cross-sectional data from 466 young Black and Latinx SMM and TW living in four high HIV-burden US cities enrolled in the PUSH Study, a status-neutral randomized control trial to increase HIV prevention and treatment adherence. We examined data for patterns of polysubstance use comparing age differences of use and explored associations between substance use and sexual partnership factors - inconsistent condom use, pressure to have condomless anal sex, and older partner, using bivariate and multivariate analyses. Results: Most participants described prior substance use with alcohol and cannabis being most common (76% each) and 23% described other illicit drug use, including stimulants, cocaine, hallucinogens, sedatives, opioids, and inhalants. Polysubstance use was common with nearly half (47%) of participants reporting alcohol and cannabis use, 20% reporting alcohol, cannabis, and one other illicit drug use, and 19% reporting alcohol or cannabis use plus one other illicit drug use. Polysubstance use was associated with greater adjusted odds of pressure to have condomless anal sex, older partner (>5 years older), and inconsistent condom use. Conclusions: Associations of polysubstance use with sexual practices and sexual partnerships that are known predictors of HIV acquisition or transmission among Black and Latinx SMM and TW underscore the need for combination interventions that include substance use treatment alongside antiretroviral-based and partner-based HIV prevention and treatment interventions.Trial Registration: ClinicalTrials.gov Identifier: NCT03194477.

Protein sources influence both apparent digestibility and gastrointestinal evacuation rate in juvenile slipper lobster (Thenus australiensis)

Apparent digestibility and gastrointestinal evacuation rate were measured to assess the potential of five commercially available protein sources for their inclusion in feeds for juvenile slipper lobster, Thenus australiensis. Protein sources tested were fishmeal, krill meal, lupin meal, soybean meal and squid by-product meal. Apparent digestibility of crude protein ranged from 79.6% to 95.3%, with fishmeal protein significantly less digestible than lupin meal, squid by-product meal and soybean meal. Gastrointestinal evacuation rate was estimated from marker replacement, where yttrium oxide replaced ytterbium oxide. Faeces were collected every 3 h for 48 h, and a kinetic model was used to calculate the rate and time for the second marker to replace the first marker. Gastrointestinal evacuation (≥ 95%) was completed between 4 and 6 h with no significant differences among protein sources. Faeces consisted of both markers in equal parts 2.7 to 5.0 h after the feed switch, with lupin meal reaching the midpoint significantly faster than squid by-product meal and reference feed. The present study is the first in crustaceans to examine the relationship between apparent digestibility and gastrointestinal evacuation, showing more digestible protein sources had slower evacuation rates. The combined approach provides deeper insight into crustaceans' digestive physiology and helps understand their ability to digest specific ingredients. Further research is recommended to understand protein requirements in a broader context to verify highly digestible protein sources meet all nutritional requirements.

Gaps in science and evidence-based interventions to respond to Intimate Partner Violence among Black gay and bisexual men in the U.S.: A Call for An Intersectional Social Justice Approach

Intimate Partner Violence (IPV) is a prevalent, but underrecognized issue among sexual minorities (SM) broadly, but especially among Black Gay and Bisexual Men (BGBM). Over the last several years, acts of IPV among BGBM made national news, drawing attention to the unique ways that IPV plays out within this particular population. Yet, little research has examined the intersections between race and sexuality among BGBM, the lack of culturally responsive IPV services, their support needs, or the barriers that BGBM face when seeking IPV related services. When examined closely, the field of IPV has traditionally focused on cisgender heterosexual white woman as victims and cisgender white men as perpetrators, which has historically impacted the availability and quality of IPV services for other populations. This narrative critique of the IPV movement calls for an intersectional social justice and health equity approach to address the unique and intersectional needs of BGBM who experience IPV. By centering the intersectional needs of BGBM and the role that racism, homophobia, and heteronormative has played in shaping IPV-related services, this article challenges the IPV field to advance a social justice orientation in order to address the unmet needs of BGBM who experience IPV.

Providing Unique Support for Health Study Among Young Black and Latinx Men Who Have Sex With Men and Young Black and Latinx Transgender Women Living in 3 Urban Cities in the United States: Protocol for a Coach-Based Mobile-Enhanced Randomized Control Trial

BACKGROUND

The US National HIV/AIDS Strategy 2020 calls for increasing access to care, improving outcomes of people living with HIV, and targeting biomedical prevention efforts, including access to pre-exposure prophylaxis (PrEP) in communities where HIV is most heavily concentrated. The cities of Baltimore, Maryland (MD); Washington, DC; and Philadelphia, Pennsylvania (PA) are disproportionately burdened by high rates of new cases of HIV infection, with high prevalence among young Black and Latinx men who have sex with men (YBLMSM) and young Black and Latinx transgender women (YBLTW) aged 15-24 years.

OBJECTIVE

This study aims (1) to identify and recruit YBLMSM and YBLTW who are at risk or living with HIV in Baltimore, MD; Philadelphia, PA; and Washington, DC, using respondent-driven sampling (RDS) with targeted seed selection, and (2) to assess the efficacy of a coach-based mobile-enhanced intervention (MEI) compared with standard of care (SOC) to increase successful engagement and retention into HIV, PrEP, and substance use treatment care across the HIV care and prevention continua in 3 Mid-Atlantic cities. This paper describes the protocol and progress as of October 20, 2019.

METHODS

This study uses a multiphase mixed methods design. The first phase is a formative, qualitative research with focus group discussions and key informant interviews. The second phase consists of evaluating the ability of RDS with targeted seed selection. The third phase includes 2 embedded randomized controlled trials (RCTs), where participants complete a baseline sociobehavioral survey, rapid HIV testing, and eligible youth enroll in parallel status-dependent RCTs that randomize the participant to 1 of 2 study arms: MEI with coach or SOC. Participants are asked to complete a web-based survey and provide biologic specimens-HIV-1 RNA (viral load) or HIV-1 antibody test and urine drug screen-at baseline and at 3, 6, and 12 months, and an exit interview at 18 months.

RESULTS

A formative qualitative research was conducted in February 2017 and May 2018, and this led to further refinement of recruitment and study methods. Aim 1 recruitment began in September 2017 with subsequent enrollment into the RCTs. Recruitment is ongoing with 520 participants screened and 402 (77.3%) enrolled in aim 1 by October 2020. Of these, 159 are enrolled in the 2 randomized trials: 36 (22.6%) HIV-positive not virally suppressed (aim 2) and 123 (77.4%) high-risk HIV-negative (aim 3).

CONCLUSIONS

This study has the potential to significantly impact the medical and substance use services provided to YBLMSM and YBLTW in the United States by providing rigorous scientific evidence outlining approaches and strategies that improve the uptake and engagement of YBLMSM and YBLTW in the HIV treatment and prevention continuum.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03194477; https://clinicaltrials.gov/ct2/show/NCT03194477.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17269.

Physiological status and nutritional condition of cultured juvenile Thenus australiensis over the moult cycle

The moult cycle is arguably the most critical aspect of crustacean biology and is associated with dramatic changes in behaviour, physiology and condition. Here we describe the first detailed investigation of the combined changes in morphology, physiological status and nutritional condition over the moult cycle of juvenile T. australiensis. Haemolymph refractive index (measured as Brix) was evaluated as a non-destructive method for predicting physiological status and nutritional condition. Post-moult, inter-moult and pre-moult stages were identifiable by microscopic examination of the pleopod distal tips, though differentiation of the pre-moult substages was not possible using this technique. Monitoring of ecdysial suture lines on the exoskeleton gill chambers was found to be highly useful for visually determining progression through the pre-moult stage and predicting the timing of ecdysis. A classical pattern of inter-moult growth was observed where size and wet weight remained relatively uniform over the moult cycle while highly significant changes in whole-body composition were simultaneously observed over time. Growth was most evident by changes in dry weight and dry matter content which more than doubled by the onset of pre-moult. Changes in dry matter content were generally mirrored by Brix and whole-body crude protein, total lipid and gross energy content. Brix strongly correlated with dry matter content and significant correlations were also found for all other primary measures of nutritional condition. Typical moult-related changes were also found for circulating ecdysteroids. This study clearly demonstrates pronounced cyclical changes in physiology and condition of juvenile T. australiensis over a typical moult cycle. The significant correlations between haemolymph and whole-body composition validates Brix as a practical and non-destructive method to objectively assess physiological status, nutritional condition and quality in T. australiensis and further demonstrates its potential for individual crustacean assessment in experimental research and practical commercial applications.

Biopsychosocial Mechanisms Linking Gender Minority Stress to HIV Comorbidities Among Black and Latina Transgender Women (LITE Plus): Protocol for a Mixed Methods Longitudinal Study

Background

Black and Latina transgender women (TW) experience a disparate burden of HIV and related comorbidities, including poor mental health and cardiovascular disease (CVD) risks. Pervasive multilevel stigma and discrimination operate as psychosocial stressors for TW living with HIV and shape health disparities for this population. Gender-affirming hormone therapy (GAHT) is commonly used by TW to facilitate alignment of the body with gender identity; in the context of stigma, GAHT may both improve mental health and increase CVD risks.

Objective

This study aims to quantify the longitudinal relationship between stigma and chronic stress among black and Latina TW living with HIV. Secondary objectives include identifying pathways linking chronic stress to HIV comorbidities and exploring chronic stress as a mediator in the pathway linking stigma and GAHT to CVD comorbidities.

Methods

This US-based mixed methods longitudinal study will enroll a prospective cohort of 200 black and Latina TW living with HIV, collecting quantitative survey data, qualitative interviews, and biomarkers of chronic stress. Interviewer-administered surveys will include validated psychosocial measures of self-reported stigma and discrimination, perceived stress, CVD risk factors, mental health, access to gender-affirming care, coping, and social support. Medical record abstraction will collect data on GAHT use, CD4 count, HIV viral load, antiretroviral therapy, treatment, and comorbid conditions. Clinical measures will include physiological biomarkers as well as salivary and blood-based biomarkers of chronic stress. Survey data will be collected every 6 months (baseline, and 6, 12, 18, and 24 months), and biospecimens will be collected at baseline and at 12 and 24 months. A purposive subsample (stratified by use of GAHT and presence of depressive symptoms) of 20 to 30 TW living with HIV will be invited to participate in in-depth interviews at 6 and 18 months to explore experiences of intersectional stigma, chronic stress, and the role of GAHT in their lives.

Results

This study was funded by the National Institute on Minority Health and Health Disparities in December 2018. The study community advisory board and scientific advisors provided critical input on study design. Recruitment began in October 2019 (n=29 participants as of submission) and data collection will continue through 2022, with publication of baseline results anticipated summer 2021.

Conclusions

This study will focus on black and Latina TW living with HIV, an understudied health disparities population, advance both stigma and intersectionality research, and move chronic stress physiology research toward a more nuanced understanding of sex and gender. The comprehensive methodology will support the exploration of the role of exogenous estrogen in the pathways between stress and HIV comorbidities, elucidating the role of GAHT in the stress-health relationship. Finally, this study will provide longitudinal evidence of the impact of stigma-related chronic stress on the lives of black and Latina TW living with HIV integrating qualitative and quantitative data with psychosocial, clinical, and biological measures.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17076

Psychometric properties and reliability of the Assessment Screen to Identify Survivors Toolkit for Gender Based Violence (ASIST-GBV): results from humanitarian settings in Ethiopia and Colombia

Background

Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia.

Methods

Several strategies were used to validate ASIST-GBV, including a 3 month implementation to validate the brief screening tool with women/girls seeking health services, aged ≥15 years in Ethiopia (N = 487) and female IDPs aged ≥ 18 years in Colombia (N = 511).

Results

High proportions of women screened positive for past-year GBV according to the ASIST-GBV: 50.6 % in Ethiopia and 63.4 % in Colombia. The factor analysis identified a single dimension, meaning that all items loaded on the single factor. Cronbach’s α = 0.77. A 2-parameter logistic IRT model was used for estimating the precision and discriminating power of each item. Item difficulty varied across the continuum of GBV experiences in the following order (lowest to highest): threats of violence (0.690), physical violence (1.28), forced sex (2.49), coercive sex for survival (2.25), forced marriage (3.51), and forced pregnancy (6.33). Discrimination results showed that forced pregnancy was the item with the strongest ability to discriminate between different levels of GBV. Physical violence and forced sex also have higher levels of discrimination with threats of violence discriminating among women at the low end of the GBV continuum and coercive sex for survival among women at the mid-range of the continuum.

Conclusion

The findings demonstrate that the ASIST-GBV has strong psychometric properties and good reliability. The tool can be used to screen and identify female GBV survivors confidentially and efficiently among IDPs in Colombia and refugees in Ethiopia. Early identification of GBV survivors can enable safety planning, early referral for treatment, and psychosocial support to prevent long-term harmful consequence of GBV.

The Prevalence of Sexual Violence among Female Refugees in Complex Humanitarian Emergencies: a Systematic Review and Meta-analysis

Importance: Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain. Objective: Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies. Data Source: We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources. Study Selection: Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected. Data Extraction: Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2. Main Outcomes: The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings. Results: The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias. Conclusions: The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.

[Pandemic 2009/10: reflections on the utility of the vaccination actions in Hesse]

In the state of Hesse (Germany) all vaccinations were administered either by the public health-care (ÖGD) or private health-care facilities and were registered by week and age group. In the following article, the benefit of the vaccination campaign will be looked at in terms of preventable consultations due to acute respiratory tract infections (AK-ARI). AK-ARI were registered with the nation-wide sentinel of the AGI. Scenarios regarding timing and age-specific coverage are modelled. The achieved timing and age distribution was compared to assumed ideal distributions, e. g., having achieved the final coverage 2 weeks before epidemic start or having applied the used vaccine exclusively for the most affected age group 5-14 years. The timing and coverage actually achieved (7% overall) prevented an estimated 1.4% or, respectively, 1.1% of the total consultation excess. With the same amount of vaccine but ideally applied at least 2 weeks -before the begin of the epidemic and exclusively to the age group of the 5- to 14-year olds, an estimated 13.9% or, respectively, 18.2% of the total excess could have been prevented. The simulated scenarios give estimations as to what benefit potentially could have been achieved during the A(H1N1)pdm09 pandemic. Both the delayed successive access to vaccine and the not ideal age distribution reduced the benefit to about 30% of the optimum. These exemplary estimates underline the importance of timeliness and valid prioritising of vaccination campaigns, although footing on just one outcome. It appears beneficial to reduce uncertainties for a solid prioritisation by, e. g., timely extended surveillance. Short-term decisions and adoptions are likely for future campaigns, e. g., due to unexpected changes in the epidemic, demanding flexibility in the application management.

The highest attainable standard of evidence (HASTE) for HIV/AIDS interventions: toward a public health approach to defining evidence

OBJECTIVES

Evidence-driven decisions have become a standard for health interventions, policy, and programs. While randomized controlled trials (RCTs) are encouraged for public health interventions, there are limitations with RCTs as the gold standard of evidence for HIV interventions. We developed a novel system of evaluating evidence for assessing HIV preventive interventions termed the Highest Attainable Standard of Evidence (HASTE).

METHODS

The HASTE system focuses on triangulation of three distinct categories of evidence: efficacy data, implementation data, and plausibility. We conducted systematic reviews, including experimental and observational data, to assess all available interventions for men who have sex with men (MSM). We collected implementation and programmatic data using a global electronic consultation, Internet searches, and in-person consultations. We assessed plausibility with expert analyses of both biological and public health evidence.

RESULTS

HASTE includes four grades of evidence: Strong (Grade 1), Conditional (Grade 2), Insufficient (Grade 3), and Inappropriate (Grade 4). We used the HASTE system to evaluate the evidence for HIV interventions for MSM in low- and middle-income countries. Several differences emerged in the strength of recommendation with the use of the HASTE system, including strong recommendations for voluntary counseling and testing and for structural interventions.

CONCLUSIONS

The HASTE system addresses a need for an evidence evaluation tool that is specific for HIV interventions and facilitates an evaluation of biomedical, behavioral, and structural approaches using the highest standard of attainable evidence. HASTE represents a tool that balances scientific integrity and practicality in assessing the quality of evidence of preventive interventions targeting the most-at-risk populations for HIV.

Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana

Same-sex practices are stigmatized in much of sub-Saharan Africa. Cross-sectional relationships between discrimination, access to and use of health care services, and HIV knowledge among men who have sex with men (MSM) were assessed in Malawi, Namibia, and Botswana. A survey and HIV screening were used to explore these variables and the prevalence of HIV. Overall, 19% of men screened positive for HIV infection. Ninety-three percent knew HIV is transmitted through anal sex with men, however, only 67% had ever received information of how to prevent this transmission. Few (17%) reported ever disclosing same sex practices to a health professional and 19% reported ever being afraid to seek health care. Men reported ever been denied health care services (5%) and 21% had ever been blackmailed because of their sexuality. Strong associations were observed between experiences of discrimination and fear of seeking health care services. Characterizing the relationship between stigma and health care seeking practices and attitudes can inform the development and implementation of HIV interventions for African MSM.

A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho

Background

Evidence is increasing of high HIV risks among southern African men who have sex with men (MSM). This represents the first study of HIV risks and human rights contexts among MSM in Lesotho.

Methods

Two hundred and fifty-two men who reported ever having anal sex with another man were accrued with snowball sampling and were administered a structured quantitative instrument in October and November 2009.

Results

Of the participants, 96.4% (240/249) were ethnic Basotho with a mean age of 26.3 years (range 18-56), 49.6% (124/250) were currently employed, and 95.2% (238/250) had at least a secondary-level education. Self-reported HIV prevalence was 11.6% (22/190); 54.5% (128/235) reported being tested for HIV in the last year. HIV knowledge was low; only 3.7% (8/212) of MSM knew that receptive anal intercourse was the highest risk for HIV and that a water-based lubricant was most appropriate to use with condoms.

Bivariate associations of wearing condoms during last intercourse with men include: having easy access to condoms (OR 3.1, 95% CI 1.2-8.5, p < 0.05); being older than 26 years (OR 2.3, 95% CI 1.3-4.2, p < 0.01); knowing that receptive anal intercourse is higher risk than insertive anal intercourse (OR 2.6, 95% CI 1.2-5.9, p < 0.05); wearing condoms with female sexual partners (OR 3.5, 95% 1.4-8.3, p < 0.01); using water-based lubricants (OR 2.8, 95% CI 1.4-5.5, p < 0.01); being less likely to report having been diagnosed with a sexually transmitted infecton (OR 0.21, 95% CI 0.06-0.76, p < 0.05); and being more likely to have been tested for HIV in the last year (OR 2.0, 95% CI 1.2-3.6, p > 0.05).

Human rights abuses were common: 76.2% (170/223) reported at least one abuse, including rape (9.8%, 22/225), blackmail (21.3%, 47/221), fear of seeking healthcare (22.2%, 49/221), police discrimination (16.4%, 36/219), verbal or physical harassment (59.8%, 140/234), or having been beaten (18.9%, 43/228).

Conclusions

MSM in Lesotho are at high risk for HIV infection and human rights abuses. Evidence-based and rights-affirming HIV prevention programmes supporting the needs of MSM should be developed and implemented.

[Timely registration of fatalities in the state of Hessen. Experiences during the influenza A/H1N1 pandemic]

Timely registration of fatalities is important for the assessment of course, extent, risk of age groups, and magnitude or severity of health threats. Nevertheless, timely data of casualties are not available on the state or national level. The current paper describes the implementation and structure of a surveillance system for the timely registration of casualties in the state of Hesse (Germany) and the experience obtained during the pandemic 2009/10. The delay of the case-based registration appears tolerable and after 2 weeks more than 80% of all deaths for a given week are registered. In 2008, the forwarding of the electronically registered data from the registry offices (95% of all cases) to the state statistical office (HSL) had been accelerated from a monthly to a weekly base. The HSL provides--on a weekly basis--this case-based data in accordance with data protection rules to the Hesse State Health Office (HLPUG, "Hessischer Landesprüfungs- und Untersuchungsamt im Gesundheitswesen"). During the pandemic, the data allowed assessment of the excess mortality with a delay of 2 weeks. No significant excess mortality was apparent; however, a slight increase was observed in the age groups 15-34, 35-49, and 50-59. Correlation of time with the severity of the A/H1N1v epidemic was not very strong. Hence, the data did not indicate an excess significantly exceeding the number of death cases registered with the mandatory reporting system of 21 cases for Hesse.

[H1N1 pandemic. Measures and experiences on the state level]

In order to establish a joint pandemic strategy, the German states ("Länder") together with the German federal government ("Bund") agreed on joint preparations for pandemic scenarios. This included the description of procedures, such as infection control measures, stockpiling of antiviral drugs, and contracts with vaccine manufacturers to ensure supply of vaccines in the event of a pandemic. The situation during the influenza H1N1 pandemic differed from that planned so that many short-term adjustments were required. It highlighted the need to make pandemic planning more flexible. In spite of several obstacles which had to be overcome during the situation, the states managed to achieve a relatively coordinated procedure and provided the availability of vaccines. In the course of the pandemic, gaps and shortcoming in existing surveillance systems were identified, which should lead to further improvements. A key point for future pandemic events is successful communication between all interested parties, especially with the medical profession, to increase the acceptance of public policies.

Rolle der Gesundheitsbehörden der Länder bei der Verhütung und Bekämpfung von Infektionskrankheiten

The goal is to describe the structure of administration for the control of infectious diseases in the German states. Internationally there is an increasing risk of potentially global transmission of infectious diseases and therefore increasing need for improved control mechanisms which are viable locally, regionally and internationally. The international public health community must ensure that responses to infectious disease with a potential impact on more than one county entail concerted action, clear communication and decision making by diverse administration agencies. Given Germany's federal structure, the 16 states have differing protocols delineating responsibilities for infection control systems. This paper provides an overview, going into detail only with regard to the administration structure in Hesse. In 2001, the German law governing infectious disease control was amended and significantly expanded. With regard to protection of humans from infectious disease, each state must define its schedule of responsibilities on the resulting scope of duties. Each state in Germany has entrusted the local public health service at the county level with the responsibility for infection prevention and control. As a rule, at the state level both an expert agency and one or more district administration agencies have been installed; these work directly with the Ministry of Health at the state level. In addition to this, Hesse has established a "centre of competence for highly contagious diseases." In the event of an infectious emergency, this network provides special treatment of highly infectious patients and expertise for public health services and the Ministry of Health on a 24-h shift basis. In times of ongoing structural transformation, it is important to emphasize that expertise at the state level is not an alternative to maintaining enough specialised personnel in the public health services themselves. Specialized practitioners are needed to ensure professional and fast-acting responses, both for the prevention and control of infectious diseases.

Management bioterroristischer Anschläge mit gefährlichen infektiösen Agenzien

The ongoing discussion on threats by terrorist attacks leads to a realignment of tasks and responsibilities within the health care system. Especially the public health services are developing from exercising mainly an advisory function to becoming an integral part in disaster response to devastating biological scenarios. Recent risk assessment recommends authoritative integration of public health officials into disaster response planning and to define their role inside the command and control structures of disaster management. Interdisciplinary networks of public health services, medical treatment centres, emergency medical services, reference laboratories and hospital hygiene services have appeared to be successful in the management of life-threatening, contagious diseases and unexpected bioterrorist incidents as well. In March 2003 the "StAKoB" was established as a permanent working group of the centres for prepared ness and treatment. Major objectives of the working group are ex change of information, mutual support in cases of emergency and standardisation in staff training.

Management biologischer Gefahrenlagen

Das Management möglicher Szenarien nach der Freisetzung biologischer Stoffe in krimineller oder terroristischer Absicht ist im Wesentlichen abhängig von der Anzahl primär kontaminierter und medizinisch zu versorgender Personen, von der Übertragbarkeit und dem Übertragungsmodus des Erregers auf den Menschen und von der Überlebensund Infektionsfähigkeit der freigesetzten Keime in der Umwelt (Tenazität). Sind die Erreger von Mensch zu Mensch übertragbar, ist eine effektive Strategie zur Kontrolle der weiteren Ausbreitung davon abhängig, welche Übertragungswege zu erwarten sind und welche durchsetzungsfähigen Maßnahmen den Gesundheitsbehörden zur Verfügung stehen, um die Infektketten zu unterbrechen. Das Management unterscheidet sich dann nicht mehr von dem bei natürlichem Auftreten einer Infektionskrankheit (Beispiel SARS). Unabhängig davon,ob Infektionskrankheiten natürlicherweise auftreten oder absichtlich zu terroristischen Zwecken ausgebracht wurden, ist es notwendig, Vorsorge für die Versorgung der betroffenen, meist schwer kranken Menschen zu treffen. Die Versorgungsmöglichkeiten sind wiederum davon abhängig, wie viele Menschen gleichzeitig erkranken und welche Schutzmaßnahmen für Personal und Umwelt bei der Behandlung erforderlich sind. Art, Zeitpunkt und Ort des Auftretens neuer oder veränderter Mikroorganismen oder der Freisetzung möglicherweise auch genetisch veränderter Erreger können nicht vorherbestimmt werden. Ballungsräume tragen allerdings allein wegen der Vielzahl von Menschen auf begrenztem Raum ein größeres Verbreitungsrisiko. Einzelne Erkrankungsfälle von bekannten oder neuen hochkontagiösen lebensbedrohlichen Erkrankungen können zentral auf Stationen mit besonderen technischen Einrichtungen und Personalschutzkonzepten (Isolierstationen) versorgt werden. Bei einer Vielzahl von betroffenen Personen muss jedoch jede Region in der Lage sein, die Versorgung von Kranken und das Management zur Eindämmung der Weiterverbreitung selbst und möglicherweise ohne Unterstützung von außen bewältigen zu können.

Conceptional considerations for a German influenza pandemic preparedness plan

A pandemic appearance of influenza A virus must be expected at any time. The limitations of health preserving and life-saving resources, which will inevitably be reached in the event of a pandemic, will be accompanied by ethical and possibly social conflicts, which can be lessened or resolved only through precautionary planning, clearly specified competencies and transparent decisions within a social consensus. In case of a shortage of vaccines and virostatic agents, decisions will have to be made with regard to the segment of the population that absolutely must be vaccinated. It is currently estimated that a (monovalent) vaccine developed for a new pandemic strain would only suffice for the single vaccination of approximately half of the German population after a year; only 10-14 million vaccine dosages would be available to provide basic immunization and single boosters to personnel required to maintain basic medical care and essential infrastructure after half a year. In the event of local influenza outbreaks, antiviral chemotherapeutic agents could be used to close the gap until a vaccine can become effective. Even if suitable influenza vaccines and virostatic agents are not sufficiently available at the start of a pandemic, it is still possible to at least prevent an outbreak of two of the most feared secondary infections that accompany influenza: pneumococcal pneumonia or meningitis and illnesses resulting from Haemophilus influenzae. Agreement still needs to be reached with manufacturers for guaranteeing the necessary vaccine production or ensuring that they have a sufficient stock to meet the minimum demand for antiviral agents and agents for symptomatic treatment.

Management of patients in Germany with suspected viral haemorrhagic fever and other potentially lethal contagious infections

Patients suffering from viral haemorrhagic fevers must be handled specifically. The clinical diagnosis of these diseases in the initial stage is difficult because early symptoms are non specific. In Germany, specific diagnosis is available at two diagnostic centres with biosafety level 4 facilities. Five high security infectious disease isolation units for patient care are available in Munich, Leipzig, Hamburg, Berlin, and Frankfurt. In addition, a corresponding number of centres of competence are established to offer support and advice to the hospitals initially treating the patients and to the local public health officers. The decentralisation of these centres of competence is recommended to allow for more timely and reactive responses to VHF epidemic threats. The risk categorisation for contacts has proved to be very useful in practice.

Influenza pandemic: preparedness planning in Germany

The following conceptual framework formed the basis for a common decision made by the health ministers of Germany's 16 federal states to set up an influenza pandemic preparedness plan. The worst case scenario was used, on the basis of the data from the pandemic of 'Spanish flu', in 1918-20. The priority groups for vaccination were assessed, as well as the potentially available antiviral treatments. National policies could be highly improved by a common European view.

[Skelefon framework concept for defence against risks in unusual epidemics: steps by public health offices]

Necessary anti-epidemic measures have to be promulgated or taken immediately in case of a suspected case of pneumonic plague or a viral haemorrhagic fever which can be transmitted from human to human. A live threatening highly contagious infectious disease may occur at any place in Germany. Therefore each health office should have the relevant information on the available infrastructure in Germany concerning treatment and competence centres, diagnostic laboratories, dispatch of samples and patient transportation. They should also be able to give qualified recommendations to physicians and hospitals concerning the necessary measures in such a case. Contacts at risk have to be notified. Based on a risk assessment and the special living conditions of the contact person they should decide if and which further measures have to be initiated, especially in the case of post-exposure prophylaxis, separation and prohibition of work. In general, imported cases of dangerous infectious diseases quickly find the interest of the media, including all the implications resulting from this. A well-organized cooperation with the media and public relations helps to avoid unnecessary irritations and panic.

Breakpoint within the nucleolus organizer region resulting in a reciprocal translocation t (4;14)(q21;p12)

Reciprocal translocations involving a break in the nucleolus organizer region (NOR) are rare. A balanced translocation in a mother and her fetus with breakpoints in the NOR at 14p12 and on the long arm of a chromosome 4 at band 4q21 is described. The rearrangement was characterized by Ag-NOR staining, multiplex fluorescence in situ hybridization (M-FISH), and FISH with rDNA probes. This and other cases with breakpoints within NORs are discussed.

Multiplex-FISH for pre- and postnatal diagnostic applications

For >3 decades, Giemsa banding of metaphase chromosomes has been the standard karyotypic analysis for pre- and postnatal diagnostic applications. However, marker chromosomes or structural abnormalities are often encountered that cannot be deciphered by G-banding alone. Here we describe the use of multiplex-FISH (M-FISH), which allows the visualization of the 22 human autosomes and the 2 sex chromosomes, in 24 different colors. By M-FISH, the euchromatin in marker chromosomes could be readily identified. In cases of structural abnormalities, M-FISH identified translocations and insertions or demonstrated that the rearranged chromosome did not contain DNA material from another chromosome. In these cases, deleted or duplicated regions were discerned either by chromosome-specific multicolor bar codes or by comparative genomic hybridization. In addition, M-FISH was able to identify cryptic abnormalities in patients with a normal G-karyotype. In summary, M-FISH is a reliable tool for diagnostic applications, and results can be obtained in </=24 h. When M-FISH is combined with G-banding analysis, maximum cytogenetic information is provided.

Spinal and bulbar muscular atrophy (SBMA): somatic stability of an expanded CAG repeat in fetal tissues

Spinal and bulbar muscular atrophy (SBMA) is a rare X-linked motor neuron degenerative disease caused by an expanded trinucleotide repeat. Unlike most other trinucleotide repeat diseases, SBMA shows limited meiotic instability, and evidence thus far indicates absence of somatic instability in adults. Data regarding the presence of fetal tissue somatic mosaicism is unavailable. We present a family in which a woman whose father had SBMA requested prenatal testing. After informed consent. molecular genetic evaluation showed the male fetus to carry the SBMA repeat elongation. Testing of fetal tissues after elective pregnancy termination showed no somatic mosaicism in the CAG repeat length. This is the first report of molecular genetic analysis of multiple tissues in an affected fetus, and only the second report of prenatal diagnosis in SBMA.

[Numerical chromosome aberrations in abortion tissue. Comparison of conventional cytogenetics and interphase cytogenetics in paraffin sections and nuclear suspensions]

Chromosomal aberrations are an important cause of spontaneous abortions. In order to detect numerical aberrations, paraffin-embedded tissue from 26 abortions with known conventional cytogenetic findings (CCG; 25 numerical aberrations and one partial trisomy 7p) was analyzed by means of interphase cytogenetics (ICG) using centromer-specific DNA probes for chromosomes #X, #Y, #10, #18, and #13/#21. Limit-values for the diagnosis of aneusomy in tissue sections were established by classifying the distribution of hybridization signals by CCG data (for gain > or = 15% of nuclei with +1 signal; for deletion > 40% of nuclei with -1 signal). Signal distribution in tissue sections and nuclear suspensions from paraffin blocks analyzed in parallel showed statistically a highly significant correlation (P < 0.0001). ICG and CCG diagnoses corresponded in 18 of 20 cases suitable for evaluation (90%; no false-positive result). No correlation between cytogenetic and histologic findings could be found. ICG proved to be a reliable tool for the detection of numerical chromosomal aberrations in paraffin-embedded tissue of abortions (sections and nuclear suspensions). This, data for genetic counselling of the parents can be provided. The limit values for diagnosis of aneusomy could also be important for the application of ICG in tumor cytogenetics.

Trisomy 18 in chorionic villus sampling: problems and consequences

Among 1547 patients undergoing first-trimester prenatal diagnosis, 100 fetal chromosome aberrations were detected. Thirteen of these involved chromosome 18. In two structural abnormalities of chromosome 18, the aberration could be excluded in amniotic fluid cells and two healthy infants were born. Trisomy 18 was not confirmed in amniotic fluid cells in three trisomy 18 mosaics. In eight non-mosaic trisomy 18 first-trimester diagnoses, the diagnosis was excluded by amniotic fluid cells or fetal cultures in four, and confirmed in the remaining four. Diagnosis of chromosome 18 aberrations in the direct preparation should be confirmed in the long-term culture of the chorionic villus sample or by amniotic fluid cultures.

Establishment of a human cell line (Mono Mac 6) with characteristics of mature monocytes

A monocytic cell line, termed Mono Mac, was established from peripheral blood of a patient with monoblastic leukemia. Two clones, designated Mono Mac I and Mono Mac 6, were isolated and both were assigned to the monocyte lineage on the basis of morphological, cytochemical and immunological criteria. Most importantly, the clones express NaF-sensitive non-specific-esterase, produce reactive oxygen and stain with MAb My4. Mono Mac 6, in addition, constitutively exhibits phagocytosis of antibody-coated erythrocytes in 80% of the cells and reacts with a panel of MAbs that are specific for mature monocytes, i.e., M42, LeuM3, 63D3, Mo2 and UCHMI. By contrast, the monoblastic cell lines U937 and THP-I are negative for all these markers. Only expression of My4 could be detected after differentiation induced by interferon-gamma (IFN-gamma). Similar treatment of Mono Mac I, however, resulted in staining with all the monocyte-specific MAbs mentioned above, while IFN-gamma treatment of Mono Mac 6 enhanced antigen expression. In addition, the cells showed an increased frequency of multinucleated cells with a rise from 4.8% to 21.9%. Mono Mac 6 appears to be the only one of the cell lines studied to constitutively express phenotypic and functional features of mature monocytes.

Hereditary persistence of fetal haemoglobin (HPFH) in conjunction with a chromosomal translocation involving the haemoglobin beta locus

An HPFH syndrome was found in a woman and her daughter who also carry a 'balanced' cyclic translocation of chromosome segments involving four chromosomes, with one break point located in the region of the Hb beta locus. This HPFH is characterized by 5% and 8% Hb F in peripheral blood, uneven distribution of Hb F in the red cells, and a G gamma/G gamma + A gamma ratio of 0.4. The mapping of the non alpha gene cluster shows no detectable deletion in the entire gamma-delta-beta-globin gene region.

Specific translocation t(4;11) in an infant with acute lymphoblastic leukaemia of null cell type

A case of acute lymphoblastic leukaemia of null cell type in infancy showed the specific reciprocal translocation t(4;11) (q21;q23) reported 16 times so far in the world literature. The proportions of abnormal and normal metaphases throughout the course of the illness correlated well with the clinical picture, but even during the short term remission metaphases expressing the translocation were still identifiable in appreciable numbers. Comparison between cytogenetic analyses of cultured and native bone marrow, PHA-stimulated and non-stimulated peripheral blood demonstrated the gradual conquest of the periphery by the abnormal clone. The importance of chromosomal changes and their interpretation for diagnosis, classification and prognostic judgment in haemotologic neoplasms is discussed in the light of the reported case.

[Prenatal diagnosis in parents with a balanced structural chromosome aberration (author's transl)]

By means of 10 case reports, the significance of prenatal diagnosis and the risk for the progeny of parents with a balanced structural chromosomal aberration are demonstrated. The aberrations were ascertained through: a previous malformed child, previous miscarriages or stillbirths or through fetal cell analysis during prenatal diagnosis performed for independent reasons. Theoretical considerations concerning the estimates of risk figures in these families are presented and the currently available risk values which are the basis of the indication for prenatal diagnosis, given.

Prenatal diagnosis of Lesch-Nyhan syndrome and some characteristics of hypoxanthine-guanine phosphoribosyltransferase and adenine phosphoribosyltransferase in human tissues and cultivated cells

Activities of phosphoribosyltransferase for hypoxanthine and adenine were investigated in erythrocytes and human tissues of fetuses and adults as well as in cultivated fibroblasts and amniotic fluid cells. Kinetic characteristics of these enzymes were also studied in patients with the Lesch-Nyhan syndrome and with partial deficiency for hypoxanthine phosphoribosyltransferase (HGPRTase), and their obligate heterozygotes. The affinity of HGPRTase for both substrates in partial deficiency decreased to 13 to 20% of normal and by a less degree in its heterozygotes (50 to 65% of normal). A slight decrease in the Km for phosphoribosylpyrophosphate was observed in the case of heterozygotes for the Lesch-Nyhan syndrome. Elevated erythrocytic adenine phosphoribosyltransferase (APRTase) activity was found in fetuses, patients with the Lesch-Nyhan syndrome or with partial deficiency, and in some heterozygotes as well. However, the Km of APRTase for hypoxanthine in these subjects was the same as that in the normal adults. The HGPRTase activity in liver increased almost 4 times during the developmental period, whereas the APRTase activity remained approximately the same. In fetal liver, the APRTase activity was almost two times higher than the HGPRTase activity, whereas in fetal brain the HGPRTase activity was higher. The Km of HGPRTase for hypoxanthine in cultivated cells and human tissues were similar to that in erythrocytes and leukocytes. On the other hand, the HGPRTase affinity for phosphoribosylpyrophosphate in these cells was cconsiderably larger than in erythrocytes or in leukocytes.

Characteristics of galactokinase and galactose-1-phosphate uridyltransferase in cultivated fibroblasts and amniotic fluid cells

The kinetic characteristics of galactose-1-phosphate uridyltransferase and galactokinase in cultivated fibroblasts and amniotic fluid cells were investigated. The Km values of galactokinase for galactose at 2.0 mM ATP are 0.34 mM in amniotic fluid cells and 0.48 mM in fibroblasts. The Km values for ATP at 0.5 mM galactose are 1.25 mM and 2.10 mM. Transferase and galactokinase activities and protein content increase logarithmically during the growth of cultivated cells. The specific activity of both enzymes also increases and reaches a maximum level 10--15 days after subculture. The specific activity of transferase increases faster than that of galactokinase in the case of amniotic fluid cells. In the case of fibroblasts the specific activity of galactokinase increases faster than that of transferase.